Provider Demographics
NPI:1922554203
Name:RODRIGUEZ, DEIDRA ANN (AUD)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:ANN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-4101
Mailing Address - Country:US
Mailing Address - Phone:201-274-6156
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-901-6901
Practice Address - Fax:718-577-5820
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002672231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist